Independence is committed to providing our members with high-quality,
comprehensive, cost-effective prescription drug coverage. The prescription drug
coverage includes a formulary feature, which is a list of drugs approved by the
U.S. Food and Drug Administration (FDA) and selected by the Independence
Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from
the area. The formulary drugs are selected based on their reported medical
effectiveness, safety, and value.
FutureScripts® manages the administration and claims
processing of Independence’s prescription drug programs. FutureScripts
works with the community, mail-order, and specialty pharmacies to provide
medications and customer service to our members and providers. The
effectiveness and safety of drugs and drug-prescribing patterns are monitored
by FutureScripts.
Select Drug Program®
The Select Drug Program formulary is organized by cost-share tiers. The
non-preferred tier on the formulary is generally associated with a higher
cost-sharing than the preferred brand or the generic tiers. Usually, when a
brand-name drug has a generic equivalent, the brand-name drug is covered at the
non-preferred level of cost-sharing while the generic equivalent is covered at
the lowest level of cost-sharing.
- Tier 1 – Generic: Includes most generic medications.
Drugs are covered at the lowest formulary level of cost-sharing.
- Tier 2 – Preferred Brand: Includes preferred
brand-name medications. Drugs are covered at a higher formulary level of
cost-sharing.
- Tier 3 – Non-Preferred Drug: Includes non-preferred
medications. Drugs are covered at the highest non-formulary level of
cost-sharing.
Some brand-name drugs without generic equivalents, authorized generic drugs,
and some generic drugs are also covered at the non-preferred level of
cost-sharing because there are cost-effective alternatives on the preferred or
generic tiers to treat the same condition.
You can download the latest Select Drug Program Formulary or call
1-800-ASK-BLUE (1-800-275-2583) to request a printed copy.
Value Formulary
The Value Formulary is organized by cost-share tiers similar to that of the
Select Drug Program. However, drugs not included on the Value Formulary are
considered non-formulary. Non-formulary drugs have covered equivalents and/or
alternatives used to treat the same condition. New drugs are not included on
the Value Formulary until reviewed by the Pharmacy and Therapeutics Committee
(P&T). Formulary placement is determined upon review by the P&T
Committee.
Non-formulary exceptions for Value Formulary
members
Providers may request consideration of formulary coverage of a non-formulary
drug when there has been a trial of, or contraindication to, at least three
formulary alternatives when available. The provider should complete a
non-formulary exception request form to provide details to
support use of the non-formulary drug and fax the request to
1-888-671-5285. If the non-formulary exception request is
approved, the drug will be covered at the highest applicable level of
cost-sharing. Please note that safety edits, such as quantity limits, will
still apply. If the request is denied, the member and provider will receive a
denial letter which includes appeal rights and instructions.
Coverage for drugs is based on the member’s prescription drug
benefits. You can download the latest Value Formulary or call 1-800-ASK-BLUE
(1-800-275-2583) to request a printed copy.
Mail-order services
FutureScripts provides mail-order services as an option for Independence
members to receive their medications. Most of the time, medication requests are
processed upon receipt of a prescription from a provider. However, there may be
times when the provider will be contacted by FutureScripts for medication
coverage, such as when the requested drug requires prior authorization and/or
safety edits apply. To determine if the drug you prescribed requires prior
authorization, please refer to the Formulary Lookup tool on ibx.com. To access the tool, go
to Drug Formularies, select the member’s formulary and
then select Find a Formulary Drug. For Value Formulary members, the provider
will also need to select a tier level before accessing the Lookup tool. For
information on how to request a prior authorization for a drug please review
the “Prescribing safety” section in this article.
Generic equivalent drugs
According to the FDA, generic drugs are equivalent to their brand-name
originator in active ingredients, dosage, safety, strength, and performance and
are held to the same strict standards as their brand-name counterparts. The
only noticeable difference between a generic drug form and its brand-name
counterpart may be the shape and/or color of the drug. Generic drugs are
generally as effective as their brand-name counterparts. However, they may cost
up to 70 percent less, which helps to reduce health care costs for members. The
generic drug option is generally the lowest cost for the member.
FutureScripts does not determine when a generic drug will be provided at the
pharmacy. In accordance with state laws, generic drugs may be provided by the
pharmacist at the point of sale, if available, unless the prescriber indicates
“dispense as written” or “brand medically necessary” on
the prescription. If a brand-name drug is prescribed in place of a generic
drug, prior authorization may be needed before the drug is dispensed and the
member will be responsible for the higher cost-sharing associated with a
brand-name drug.
Therapeutic alternative drugs
Drugs that differ chemically but have the same effect are called
“therapeutic alternatives.” These drugs will generally be in the
same therapeutic class. For example, ibuprofen and naproxen are both
non-steroidal anti-inflammatory drugs that can be therapeutically interchanged
in most cases.
Examples of therapeutic alternatives are:
Brand name drug
|
Therapeutic alternative(s)
|
Dulera®
|
Advair® Diskus,
Symbicort®,Breo-Ellipta®
|
OxyContin®
|
morphine sulfate ER, Xtampza® ER
|
Levemir® and Tresiba®
|
Lantus®, Toujeo®
|
Although they are not the exact chemical equivalents of the brand name
drugs, therapeutic alternatives treat medical conditions in a similar way.
Specialty drugs
Specialty drugs meet certain criteria, including, but not limited to drugs
used to treat rare, complex, or chronic disease, drugs that have complex
storage and/or shipping requirements, and drugs that require comprehensive
patient monitoring and/or education. Specialty drugs covered under the pharmacy
benefit may be managed by FutureScripts. Benefits may vary, and many plans
cover specialty drugs on a specialty tier with higher cost-sharing.
Formulary tier exceptions
Providers may request an exception for a non-preferred drug to be covered at
a preferred level of cost-sharing when there has been a trial of, or
contraindications to, at least three formulary alternatives. This option is
available based on benefit design for both Select Drug Program and Value
Formulary members. The following restrictions apply:
- Drugs on the generic, preferred brand, and the specialty tiers are not
eligible for a change to cost-share.
- Non-formulary drugs on the Value Formulary are not eligible for change to a
lower cost-share. If approved for non-formulary exception, the members will pay
the highest level of cost-sharing for these drugs.
- For cost-sharing purposes, authorized generic drugs are treated as
brand-name drugs and are not eligible for coverage on the generic tier(s). For
example, the authorized generic oxycodone ER is technically a brand-name drug,
not a generic of Oxycontin. Brand-name drugs are not eligible for coverage on
the generic tier. The lowest tier an authorized generic can fall on is the
preferred brand tier.
The provider should complete the formulary exception form, providing details to support the
request and fax it to FutureScripts at 1-888-671-5285. If the
tier exception request is approved, the provider will receive a fax
notification and the drug will be processed at the appropriate formulary level
of cost-sharing. If the request is denied, the provider and member will receive
a denial letter.
Prescribing safety
As part of formulary management, Independence implements safe prescribing
procedures that are designed to optimize the member’s prescription drug
benefits by promoting appropriate utilization. These procedures are based on
FDA guidelines, and the approval criteria were developed by
Independence’s Pharmacy and Therapeutics Committee. FutureScripts
continuously monitors the effectiveness and safety of drugs and drug
prescribing patterns. Several procedures, such as prior authorization and
safety edits, have been established to support safe prescribing patterns and to
promote optimal pharmacotherapy outcome for the members.
Prior authorization
Prior authorization is required for certain covered drugs to ensure medical
appropriateness and necessity. The approval criteria for these medications may
include a trial of a different drug, such as a generic equivalent drug or a
therapeutic alternative. Using these approved criteria, clinical pharmacists
evaluate requests for these drugs based on clinical data, information submitted
by the member’s provider, and the member’s available prescription
drug therapy history. The evaluation may include a review of potential
drug-drug interactions or contraindications, appropriate dosing and length of
therapy, and utilization of other drug therapies.
Coverage of certain drugs on the formulary, with or without prior
authorization (e.g., weight loss drugs, fertility drugs), may be limited based
on the member’s prescription drug benefit design.
The prior authorization process may take up to two business days once
complete information from the prescriber has been received. The prescriber will
be notified if an approval has a defined time frame, such as 12 months. Once
the approval time period expires, the provider will need to request
consideration for a new prior authorization.
Providers can access platforms such as CoverMyMeds&re
g; and SureScriptsTM that support electronic prior
authorization (ePA) to submit a prior authorization request. Alternatively, the
provider can complete a prior authorization form and fax all supporting medical
information to FutureScripts at 1-888-671-5285.
Prior authorization requirements for selected
drugs
Prior authorization requirements for selected drugs are in place for certain
medications. This expedites the review process at the pharmacy by using
information available in the member’s pharmacy benefit claim history to
determine coverage for the requested medication. For example,
Flovent® HFA is a medication that requires previous trial of
either of the preferred medications Asmanex® or
Qvar®. With the prior authorization requirements for selected
drugs, a member will be able to receive coverage immediately for
Flovent® HFA if the claim history shows a previous paid claim
for either Asmanex® or Qvar®. A manual prior
authorization request will not be needed. If the claim history does not contain
a previous paid claim of either drug, then a prior authorization request will
be needed in accordance with the standard prior authorization process.
Safety edits
Safety edits are applied to prescription medications to promote safe and
appropriate use of drugs. They are designed to align with clinical practice
guidelines and FDA approved use(s) outlined in the manufacturer package insert.
There are different types of safety edits, some of which will prompt member
counseling at the point-of-sale, others will require prior authorization
review. Examples of safety edits are age limits, quantity limits, morphine
milligram equivalent (MME) limits, high cumulative stimulant dose limit, and
concurrent drug utilization review (cDUR).
Age limits
Age limits are designed to prevent potential harm to members and to promote
appropriate use of the drug. Age groups are identified through the FDA drug
approval process. Age limits are generally noted when safety and efficacy has
not been established. If the member’s prescription falls outside of the
FDA guidelines, it may not be covered until prior authorization is obtained. In
addition, an age limit may be applied when certain drugs are more likely to be
used in certain age groups. For example, drugs used to treat Alzheimer’s
disease may require prior authorization for use in young adults. The provider
may request coverage for drugs outside of the age limit when medically
necessary. If a member’s prescription falls outside the FDA guidelines,
it may not be covered until prior authorization is obtained.
Quantity limits
Quantity limits are designed to allow a sufficient supply of medication
based upon FDA-approved maximum daily doses, standard dosing, and/or length of
therapy of a drug. There are several different types of quantity limits to
promote safe and appropriate utilization. If a member requires more than the
limit, the provider will need to submit a prior authorization request.
Limits
|
Description
|
Example
|
Quantity over time
|
This limit is based on dosing guidelines over a rolling time period.
|
Sumatriptan (Imitrex®) 50 mg, limit 18 tablets per 30 days
|
Maximum daily dose
|
This limit is based on the maximum daily dose approved by the FDA.
|
Guanfacine Extended Release 24-hour, limit 1 tablet per day
|
Refill too soon
|
This limit is in place to minimize stockpiling of prescription medications.
A prescription drug can be refilled after 75 percent utilization of its
previous fill.
|
A 30 days’ supply of atorvastatin tablets filled on 1/1/20 can be
refilled again on or after 1/24/20.
|
Day supply limit
|
This limit is based on day supply and not the quantity. However, quantity
limits may apply as well.
|
Opioids containing cough and cold products such as hydrocodone/homatropine,
limit two 5 days’ supply per 60 days and 30 ml per 1 day. The max
quantity allowed without prior authorization is 150 ml for 2 fills within 60
days. For members under 18 years of age the limit is two 3-day fills per 60
days.
|
Morphine milligram equivalent (MME)
limits
Independence applies additional safety measures to opioid products by
limiting the total daily dose. This limit accounts for all the different opioid
products through a measurement called the morphine milligram equivalent (MME)
dose. The MME is a number that is used to determine and compare the potency of
opioid medications and it helps to identify when additional caution is needed.
The daily limit is calculated based on the number of opioid drugs, their
potencies and the duration of therapy. Prior authorization is required for
opioid doses that exceed 90 MME per day.
Concurrent drug utilization review (cDUR)
Concurrent drug utilization reviews (cDURs) are built into the pharmacy
claim adjudication system to review a member’s prescription history for
possible drug-related problems including drug-drug interactions and drug
therapy duplications. Drugs may reject at the point-of-sale and/or generate a
message to the dispensing pharmacist when there is a safety concern. The
dispensing pharmacist can review the issue with the provider and override the
rejection if appropriate for most edits.
Learn more
Visit the Pharmacy section of our website for additional information
on pharmacy policies and programs.
FutureScripts is an independent company that provides
pharmacy benefits management services.